Low Back Pain... Almost Inevitable?
Eighty five percent of the population will experience at least one episode of low back pain (LBP) in their lifetime (Damkot). Annually 15-30% of adults experience LBP of which 80% will seek medical intervention. Accounting for an estimated at 15 million office visits per year. The direct care and treatment of LBP costs $25 billion annually. Indirect costs (lost wages, decreased productivity, and workman's compensation) for LBP costs $100 billion annually. Within 12 weeks of onset of symptoms, 80-90% will resolve regardless of the intervention. Recurrent LBP within the first year occurs 20-44% and 80% within 10 years .Lifetime recurrence is estimated at 85%. Sedentary people between the ages 45-60 are affected most. Prevalence of LBP higher for Caucasians than any other racial group.LBP affects both sexes equally. Dr. Nachemson reported incidence of LBP the same frequency for individuals working in sedentary positions in comparison to heavy labor jobs. Poor posture, frequency of forward bending, and loss of low back extension are predisposing factors for LBP (R.A. McKenzie). Faulty body mechanics with lifting utilizing combined bending and twisting directly correlated to mechanical LBP (P. Greenman).

Origin of LBP classified into categories:

  • mechanical
  • infectious
  • neurological
  • genetic disorders
  • psychiatric
  • rheumatologic
  • tumors & infiltrative disease
  • metabolic & endocrinologic
  • hematologic diseases
  • referred pain (visceral, vascular)
Spine Rehabilitation: How do you treat Low back pain?
Treatment of low back pain is a complex issue which requires an interdisciplinary team approach of physicians with specialties in diagnostic and therapeutic injections, surgeons, physical therapists, psychologists and psychiatrists with specialty in pain management. No one specific rehab protocol has been established. Key is an individualized, customized program utilizing the interdisciplinary treatment approach.

Philosophy of treatment for LBP has shifted from a passive approach (bed rest and medication) to a more active approach utilizing exercise, specific trunk stabilization/back strengthening and manual therapy. Medication used as an adjunct and not the primary treatment. Boachie-Adjel reported 6% reduction in vertebral bone density after 2 weeks of bed rest which was not regained after 5 years of the study. Bed rest also deconditions muscles an alters normal circulation. Patient education regarding proper body mechanics, stretching and cardiovascular fitness are incorporated into the active treatment approach.

Literature reviews clearly indicate that manual therapy is more effective in the treatment of spinal (neck and LBP) pain syndromes in comparison to exercise, medication, or bedrest.

Acure et al in Spine 2003 concluded: randomized, controlled trial, significantly greater improvement with the manual therapy group versus the exercise group in all outcome measures for chronic LBP(>8weeks). Return to work 67% in the manual therapy group, and 27% in the exercise group throughout the 1 year follow-up.

Jull et al in Spine 2002 concluded: randomized, controlled trial significantly reduced cervicogenic headaches and neck pain with manipulation and exercise.

Anderson et al in N Engl J Med 1999 randomized, controlled trial concluded spinal manipulation more effective treatment for LBP than the standard medical care for patients with subacute low back pain.

Schiller et al in J Manipulative Physiol Ther 2001 randomized, controlled trial concluded spinal manipulation was an effective treatment of mechanical thoracic pain.

Zylbergold in Arch Phys Med Rehabil 1981 demonstrated the manual therapy group improved pain reduction and lumbar mobility in comparison to traditional physical therapy treatments.

Jull, Bogduk in Med J Australia 1988 demonstrated accuracy of manual diagnosis for cervical zygopophysial joint pain syndromes when compared with radiologically-controlled diagnostic injections.

Blomberg et al, Scand J Prim Health Care 1992 demonstrated manual therapy six times less likely to be on sick leave at work versus conventional therapy and less costly.

Koes et al. J Manip Physiol Ther 1993 demonstrated reduction is severity of main complaint was superior with manual therapy than physical therapy for patients with LBP > 1 year.

Blomberg et al in Spine 1994 and Blomberg, Tibblin in Clin Rehabil 1993 demonstrated manual therapy concomitant with steroid injections were superior to conventional treatment alone.

Anderson et al. J Manip and Physiol Ther 1992. A meta-analysis of clinical trials of spinal manipulation.

Koes et al in British Med J 1991. Blinded review: Spinal manipulation and mobilization for back and neck pain.

Shekelle et al in Annals of Int Med 1992. Spinal manipulation for Low back pain.

Phillips, Twomey LT in Manual Therapy 1996. A Comparison of Manual Diagnosis with a Diagnosis established by a uni-level lumbar spinal block procedure.

Deyle et al in Ann Intern Med 2000. Effectiveness of Manual Therapy and Exercise in Osteoarthritis of the knee.

THE BEST TREATMENT FOR LOW BACK PAIN... IS PREVENTION.

Manual therapy and Mechanical Low Back Pain
The pelvis consists of two innominate bones and the sacrum which articulates via two sacroiliac joints posteriorly and the pubic symphysis anteriorly. This mobile pelvic girdle can become dysfunction due to muscular imbalances causing asymmetrical loading on these joints and surrounding structures, trauma, leg length discrepancy, pregnancy, iatrogenic disorder, or idiopathic origin.

Manual structural dynamic assessment of the lumbar spine (low back) with coupled "normal" movement patterns of the pelvis and lower quadrant. Determine if the necessary movement patterns for normal gait are present or what is necessary to restore this complex chain of movement patterns. Biomechanically, the sacrum functions as an atypical lumbar vertebrae(L6), the innominate act as an extension of the lower quadrant through a complex poly-axail system. Motion within the sacroiliac joint is minimal but essential for functional gait and when lost has a significant clinical effect.

The role of SIJ pathology fell into obscurity with the discovery by:

Mixter & Barr (1934): Rupture of intervertebral disc
Verbiest (1954): Spinal stenosis and radicular syndrome from narrowing of the vertebral canal. Tangible entities with accepted pathophysiology. Not until research displayed lumbar facet syndrome pain generators and reimbursement driven market did the advent of SIJ research begin.
The "Gold standard" diagnosis of SIJ dysfunction is the intra articular(IA) SIJ injection guided by fluoroscopy. Symptom reproduction and pain relief consistent with the type of local anesthetic (Dreyfuss). "Normal" SIJ are NOT painful with IA injection.

The current research concludes that the only valid, reliable means of SIJ Diagnosis is intra-articular SIJ injection:

Dreyfuss et al. The value of History and Physical Examination I Diagnosing Sacroiliac Joint Pain. Spine 1997

Herzog W, Read LJ, Conway PJW, Shaw LD, Mc Ewan. Reliability of Motion Palpation procedures to detect sacroiliac joint fixations. J Manip. Physiol Ther 1989;12:86-92.

Fortin JD, Dwyer AP, West S, Pier J. Sacroiliac Joint: Pain referral maps upon applying a new injection/arthrography technique. Part 1: asymptomatic volunteers. Spine 1994;19:1475-1482.

Hesch J, Aisenbrey JA, Guarino J: Manual therapy evaluation of the pelvic joints using palpatory and articular spring tests. First Interdiscplinary World Congress on LBP. San Diego:CA 1992;435-459.

Laslett M, Williams M: The Reliablilty of selected provocation tests for sacroiliac joint pathology. Spine 1994;19:1243-1249.

McCombe PF, Fairbanks JCT, Cockersole BC, Pysent PB. Reproducibility of physical signs in LBP. Spine 1989;14:908-918.

Dreyfuss P., Dryer S, Griffin J. Positive sacroiliac screening tests in asymptomatic adults. Spine. 1994;19:1138-43.

Dreyfuss P, Micharlsen M., Bogduk N. The value of medical history and physical examination in diagnosing sacroiliac joint pain. Spine. 1996;21:2594-602.

Potter N., Rothstein J. Intertester Reliability for Selected Clinical test of the sacroiliac joint. American Physical Therapy Assoc. 1985;65:1671-75.

The controversy remains for the ability of the clinician to identify SIJ dysfunction. The biomechanical model used in osteopathic manual therapy bases clinically decision making on Structure and Function versus provocation testing (symptom reproduction). This provocation testing has been proven invalid and unreliable. There are manual therapy models that emphasize provocation testing as the primary means for clinical decision making process.


NOT ALL MANUAL THERAPY MODELS ARE EQUAL.

The pathomechanics within this biomechanical model determines what is primary, secondary, tertiary problems and the appropriate treatment, as well as, sequence of which to treat first.

Motion loss and its characteristics are more valuable diagnostic indicators than the presence of pain during the provocation of pain by movement.

When does treatment with a presumptive diagnosis i.e. SIJ dysfunction fail and need for a provocative study or analgesic injection (discography, IA or EA SIJ block, facet block, selective nerve root block) to determine the pain source?

Generally reserve this measure until 4 weeks of failed (no subjective or objective improvement) non-injection care (Dreyfuss).

Use a rationale algorithm for presumptive and definitive diagnosis driven care which includes educating our patients in preventing recurrent pain syndromes.

SIJ Treatment Options

  • Education
  • Medications: NSAID's, narcotics
  • Modalities: ultrasound, iontophoresis
  • Bracing (SIJ Belt)
  • Manual therapy
  • Exercise: self mobilization (joint and dural), dynamic trunk stabilization, flexibility, motor control, recruitment patterns muscles of the lower quadrant, balance muscle length of the lower quadrant, and "force closure stabilization" exercises
  • Inrta and extra articular injections
  • Denervation techniques
  • Surgery: ligamentous reconstruction?
SIJ Treament Objectives
  • Treat all regional articular, muscular/fascial, ligamentous and neural components to the SIJ regional pain complex
  • Decrease pain
  • Restore balance in joint kinematics and function
  • Establish Balance of the Lumbo-pelvis to lower extremity length and strength
  • Correct Lumbo-pelvic-Hip mechanics and recruitment patterns
  • Establish a preventative program
  • Retrain optimal movement patterns
Sacroiliac joint often misdiagnosis and treated due to pelvic asymmetry.
Asymmetry does not equate to SIJ dysfunction.
After 8-10 sessions of manipulative therapy if recurrent pelvic asymmetry, no objective improvement noted, the treatment should be amended and consideration for diagnostic testing should take place. The SIJ in this author's opinion is often manipulated excessively. It is often a secondary component or a byproduct of muscular imbalances of the trunk and lower quadrant. Recurrent SIJ dysfunction is often due the clinician failure to recognize and treat/resolve a lumbar or sacroiliac component prior. The SIJ is often a secondary component and will return until the primary sacral component has been treated.

Alternative treatment options

Prolotherapy
Objective to strengthen the ligamentous complex surrounding the SIJ by injecting dextrose-glycerine (most common) into the iliolumbar, interosseous, sacroiliac long dorsal, sacrospinous, and sacrotuberous ligaments.
Injected substance cause iatrogenic inflammation and subsequent fibroblastic migration with ligamentous fibril widening and strengthening via collagen proliferation.
Treatment attempts to strengthen the ligamentous supporting system to allow the joint to function properly in the case of presumed ligamentous weakness or laxity.
Randomized, controlled studies on prolotherapy ( Ongley, Lancet,2:143, 1987 and Klein, J Spinal Disorders, 6:23, 1993).

SIJ Denervation/ Radiofrequency

  • L5 dorsal ramus, S1-3 DR/lateral branches denervated with phenol and/or radiofrequency.
  • Selection criteria: prior blockade of nerves and/or established SIJ pain with IA SIJ block(+), discography and facet block(-).
  • Bipolar radiofrequency("railroad tracks") and /or multiple continous lesions alon the posterior joint line.Lesion descending a
rticular branches to the capsule/joint and ligaments with bipolar denervation: <10mm spacing for optimal lesioning.